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Sunday, November 25, 2012

Sesamoiditis: Email Advice

Hello Mr Blake, 

first of all thank you very much for your blog, it's very informative.
My name's Pierre and I am based in London. Could it be please possible to have your opinion on my case?
  • 3 months ago, I injured my foot playing football  - what you guys call soccer ;). I saw a foot surgeon and after X-Ray and MRI he diagnosed Sesamoiditis.
  • At first, pain was mild, and I could walk as much as I wanted and could run for one hour at the gym. I couldn't play football though.
  • A podiatrist made me some special insoles, but I think it made my shoes too tight  (they occupied too much space) or they had much "arch" thus putting pressure on toes (is it possible?) and the pain became much worse.
             Dr Blake's comment: Definitely, any shoe insole, even designed with the best intentions can place the body's weight in the wrong place, or make the shoe too tight, or create motion when the best is to limit the motion for awhile, or a combination. With orthotic therapy, much experimentation can be needed, and the technician designing the inserts has to have some tricks up the sleeves, and be willing to experiment. There is just too many factors to consider, and even if known, sometimes you just have to take an educated guess on which direction to go. Golden Rule of Foot: If the insert makes the pain worse, remove immediately, re-introduce a few more times, and if still a bother, definitely modify and do not wear until modified. 
  • I then spend a week in a removable cast, but I had to remove it because it was putting pressure on my foot / toe and was hurting even on a rest position.
             Dr Blake's comments: The removable casts for sesamoid pain must have an off weight bearing float placed into them unless immediately comfortable. See if the brace shop or Doc's office can do that for you. I typically use 1/4 inch adhesive felt, and may have to increase to 1/2 inch by doubling over. 

  • So i then used for a month crutches with no weight bearing
  • I have recently had another X-Ray and MRI (I have the CDs but I am not sure if I can attach the contents in an email). It showed the inflammation is worse than when I had the 1st X-Ray & MRI. I was told to rest and take Ibuprofen if pain for the next 3 months before another MRI and maybe operation.
Dr Blake's comment: Non weight bearing to reduce the pressure on the bottom of your foot will cause more stagnation in blood flow and the appearance of more inflammation. It is weight bearing that pushes it back toward your heart and out of your boot. So, the weight bearing cast is important as I mentioned above. I am assuming with this conversation that the MRI revealed no fracture. 
I would have the following questions please:
  • Would you know a specialist for such injury based in London? No
  • Could you please give me your thoughts/recommendations: insoles, painkillers, calcium supplements, for how long can i walk, excercises / sport I can still do etc. any advice that you think would help basically.
Dr Blake's comment: Even though you are in the Immobilization/Anti-Inflammatory Phase of Rehabilitation, finding a good doc or pedorthist to design a comfortable insole that protects the sore area will be very helpful even if surgery is needed in the future. Part of any program is to create a painfree environment. This is normally with ice packs for 10 minutes three times a day. Anti-inflammatory medication is fine if there is no bone injury. Straight pain killers are typically reserved to allow patients to get a good night sleep when needed for that function. Calcium and VitD supplements when there is a fracture is discussed at length, but it is never a bad idea to make sure you get 1500mg calcium and 1000  units VitD3 daily between dietary intake and supplements. Most patients with pain in and around the sesamoids are limited to biking with the weight on the arch, and swimming, for cardio, and multiple gym routines or pilates and yoga type. You can always pick and choose the positions to avoid or minimize. 
  • What do you think of the surgery: what's the success rate, how long after operation can I run again, are there any sports I won't be able to do again? Dr Blake's comment: What would they be operating on? Inflammation? Nothing you have said makes me want to go down that path right now!!!
Thanking you very much in advance for your time and attention. I would be very grateful if you could please send me your thoughts and a few advices, this injury is getting very frustrating I must acknowledge...
Yours faithfully, Pierre 

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.